Fluids + Nutrition Flashcards
What are the 5Rs of Fluid prescribing?
Resuscitation Routine maintenance Replacement Redistribution Reassessment
How would you give resus fluids and who needs them?
Patient showing signs of hypovolaemia
Give initial Crystalloid fluid bolus of 500ml in 15mins
Then re-assess the patient’s response.
If euvolaemia not achieved repeat this up to 2Ls over approx an hour.
If still not euvolaemic + stable then seek senior help.
What are maintenance fluids?
Adult needs 30ml/kg/day of water
and 1-2mmol Na and Cl per Kg per day
and 0.5-1mmol K per kg per day
How can you be sure that a patient is receiving sufficient fluids?
Insert a urinary catheter for accurate measurements
Enough fluid is being given in the patient’s urine output is at least 0.5ml/kg/hr
What is a colloid?
Colloids are gelatinous solutions that maintain a high osmotic pressure e.g. Gelofusion
Give examples of crystalloid fluids
0.9% NaCl = normal saline
Hartmann’s soln = Compound lactate
5% Dextrose
Why is K added separately?
Patient K needs vary greatly and mistakes in K levels can have serious consequences.
Hartmann’s only has 5mmol/L of K, the rest have no K. Most patients get K from diet but consider K if patient is NPO
What is contained in a litre of Hartman’s soln?
1L water 131 Na 111 Cl 5 K 29 Bicarb
Are all colloids isotonic?
No, dextrose is hypotonic.
Hartmann’s and normal saline are isotonic.
What is in a litre of normal saline?
1L water
154 Na and 154 Cl
What is in 5% dextrose?
1L water and 50g of glucose
What are the clinical signs of dehydration?
Dry mucous membranes
Skin turgor
Prolonged capillary refill time
Vital signs - tacky and low systolic BP
urinary output below 0.5ml/kg/hr = oliguric
below 10ml urine per hour is anuric
What do we not give pure H2O?
Would cause cell lysis and hyperkalaemia
What are the indications for providing nutritional support for a patient?
Pre existing malnutrition
Anticipated or actual inadequate intake by mouth e.g. dysphagia / pancreatic cancer, Neo-adj chemo radio
Multiple comorbidities - stroke patient
Early enteral feeding post op e.g. after upper GI sx
Parental feeding will be unable to receive adequate enteral nutrition by post op days 10-14
What is the best way to assess nutrition?
MUST score
universal screening tool for malnutrition
1. Current BMI
2. Weight 3 months ago
3. Acute disease effect score
Based on MUST score, a dietician may need to be consulted.
What is Enteral feeding?
- Delivered straight to gut
- Should be used if the gut can be used
- 3 Route Options
○ Oral
○ Feeding tube NG/NJ
○ Gastrostomy ( PEG tube) or Jejunostomy
What is parenteral nutrition?
- Can be given peripherally or centrally ( better central)
- Peripheral parenteral nutrition should be given via a large diameter venous catheter
○ Can cause phlebitis in peripheral veins
Used in patients where the bowel needs to rest e.g. bowel resection, fistula that needs to dry out
What is a PICC line?
Peripherally inserted central catheter
- A long catheter placed through a peripheral vein that end up actually entering a central vein
○ Used for TPN and chemo
○ Can be used long term and the patient can go home with it
○ Lower risk of line sepsis
What is TPN?
TPN is entire daily nutritional needs, macronutrient needs in their smaller components, also contains fluid so will be included in someone’s daily fluid plan, dieticians can add vitamins and minerals also.
What is important about the storage of TPN?
Covered by the green bag because it needs to be protected from sunlight which would denature the amino acids
What is in the bag of yellow fluid? Why would the patient be on it?
B complex vitamins - mainly thiamine b12
Given to patients with hx of alcohol dependence or long hx of vomiting
Used to prevent Wernicke’s encephalopathy
What are the complications of TPN?
• Hyperglycaemia
• Serum electrolyte abnormalities
• Refeeding syndrome
○ K, Mg, and Phosphate can be imbalanced and cause trouble quickly
• Wernicke’s encephaopathy
• Bacteraemia
• Complications secondary ot central venous catheterisation
Fatty liver - could lead to liver failure ( 2 most common cause of death in patient on long term TPN)
What should be monitored in a patient on TPN?
- Daily glucose, urea and electrolytes until stabilised
- Twice weekly LFTs
Weekly copper, magnesium, phosphate and manganese
